Medicare Scope of Appointment Form

Medicare Scope of Appointment Form

Senior Savings Network 800-729-9590
Before meeting with a Medicare beneficiary (or their authorized representative) in person or remotely, Medicare requires that Licensed Sales Representatives obtain this form to ensure that only the types of plans and products Medicare Beneficaries agree to consider are discussed in appointments. Please confirm you agree to discuss these types of plans and products.
Plan Types You Agree to Discuss*

Medicare Advantage Plans (Part C) and Cost PlansStand-alone Medicare Prescription Drug Plans (Part D)Medicare Supplement (Medigap) PlansOther Health Insurance Products, Dental-Vision-Hearing, Hospital Indemnity
Tentative Date of Appointment with a representative of Senior Savings Network:
December 31, 2025 or before. You can schedule a specific appointment on a date and time of your choosing.

By submitting this form, you agree to meet in person or remotely with a Licensed Sales Representative to discuss the products checked above. The Licensed Sales Representative is either employed or contracted by a Medicare plan and may be paid based on your enrollment in a plan. They do not work directly for the federal government. Signing this form does not affect your current or future enrollment in a Medicare plan, enroll you in a Medicare plan or obligate you to enroll in a Medicare plan. All information provided on this form is confidential.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Will more than one person be included in the appointment?*

YesNo
Additional Person Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Signature*

Clear
Should be Empty: